NIPPON EXPRESS CO.

, LTD
Pre Check Safe Work Assignment
Safe Work Instructions:
This Pre Check SWA is to be completed daily
Personal Protective Equipment Required:
before start of work. This Pre Check SWA is to be 1. List job steps associated with task.
displayed at location of work. All workers Fall Protection Hand (Gloves)
involved with the work must sign on this Pre Check 2. List hazards associated with job steps.
SWA. On completion, submit this checklist NEX  Full-Body Harness  Leather
Safety. Work to stop if work is not in accordance 3. List safe work practices to eliminate the
with safe work practice/procedure. hazards.
 Latex
Foreman: ____________________ (1) JOB STEPS
 Other  Welding
Date: _______
 Other
Location of work: __________________________
 Chemical Resistant
Describe Work:
_________________________________________
Eye/Face
 Safety glasses with side-shields
_______________________________________

Name of Workers Assigned  Goggles  Clear Goggles

______________________________
 Welding Hood  Face Shield
_____________________________
Respirator
______________________________
 Disposable  Respirator Type
______________________________ ____________

______________________________ Foot

______________________________  Safety-Toed Boots  Rubber Boots

______________________________ Head

 Safety Helmet

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 NIPPON EXPRESS CO., LTD
Hearing
 Ear Plugs  Ear Muffs
Clothing
 Chemical Resistant  Fire Retardant
Other PPE
required:__________________________
Employee Certifications Required:
Crane Operator
Forklift Operator
Mobile Equipment Operator
Vehicle Operator
Powder-Actuated Tool User
Power Tools
Competent Person (excavations, confined space,
scaffolds, hazardous material)
Other (specify)
(2) HAZARDS
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Permits Required:
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Hot Work  k. Will housekeeping be well managed?
________
Lockout/Tag out 
Signs/Barricades  l. Have areas been identified as requiring fall
Confined Space  protection systems and have they been installed?
Crane Lift  ________
Pipe Dismantle/Hot Tapping 
Scaffolds 
Hazardous Material Compliance  m. Are flammable/combustible materials stored,
Other (specify) ____________________  separated and secured? _______
For Safety: Answer the following questions Yes, (3) SAFE WORK PRACTICES
No or N/A. _________________________________________
_________________________________________
 a. Should HSE be involved in the planning of this _________________________________________
 job? ________ _________________________________________
 b. _________________________________________
 c. Will weather conditions affect the safe _________________________________________
performance of this work? ________ _________________________________________
 d. _________________________________________
 e. Have all tools, ladders, electrical cords, rigging ________
and safety equipment been inspected? _______
 f. Safety Reminders:
 g. Has a material storage area been identified and
approved? ________  Plan Every Job
 Expect the Unexpected
h. Have all scaffolds and ladders been inspected  Use The Right Tool
and signed off? ________
 Follow Procedures
 Isolate The Equipment
i. Is a fire watch or confined space attendant  Identify The Hazards
required? ________  Minimize The Hazards
 Protect The Person
j. Do you know how to summon help? ________
Workers & Supervisors shall not perform non-
routine work, which requires the use of, or
potential exposure to, a hazardous substance, which
Health, Safety & Environmental
 NIPPON EXPRESS CO., LTD
is not normally handled by workers. A review of 3. What problems did you have with today’s
this job assignment must be conducted by a work assignment?
supervisor / management before starting the work. 4. What can we do to improve performance?

Notes/Comments _______________________________________

_________________________________________ 5. Miscellaneous concerns: ___________________

_________________________________________
_________________________________________
_________________________________________ 6. Reviewed by:
_________________________________________
_________________________________________ Foreman: __________________________
_________________________________________
_________________________________________ NEX Safety: _________________________
_________________________________________
_________

Completed form is to be submitted to Section

Manager/NEX Safety on completion of the work.

SAFETY REVIEW

Foreman:
__________________________________
Date: ______/______/______

1. Was anyone injured or did an unplanned

incident occur today.
If yes, explain. Yes _____ No _____ N/A
_____
_________________________________________
_
_________________________________________
_
2. Was it reported to the safety department?
Yes _____ No _____ N/A _____

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